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Helms F, Poyanmehr R, Krüger H, Schmack B, Weymann A, Popov AF, Ruhparwar A, Martens A, Natanov R. Impact of Intercostal Artery Reinsertion on Neurological Outcome after Thoracoabdominal Aortic Replacement: A 25-Year Single-Center Experience. J Clin Med 2024; 13:832. [PMID: 38337526 PMCID: PMC10856124 DOI: 10.3390/jcm13030832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/24/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Intercostal artery reinsertion (ICAR) during thoracoabdominal aortic replacement remains controversial. While some groups recommend the reinsertion of as many arteries as possible, others consider the sacrifice of multiple intercostals practicable. This study investigates the impact of intercostal artery reinsertion or sacrifice on neurological outcomes and long-term survival after thoracoabdominal aortic repair. METHODS A total of 349 consecutive patients undergoing thoracoabdominal aortic replacement at our institution between 1996 and 2021 were analyzed in a retrospective single-center study. ICAR was performed in 213 patients, while all intercostal arteries were ligated and sacrificed in the remaining cases. The neurological outcome was analyzed regarding temporary and permanent paraplegia or paraparesis. RESULTS No statistically significant differences were observed between the ICAR and non ICAR groups regarding the cumulative endpoint of transient and permanent spinal cord-related complications (12.2% vs. 11.8%, p = 0.9). Operation, bypass, and cross-clamp times were significantly longer in the ICAR group. Likewise, prolonged mechanical ventilation was more often necessary in the ICAR group (26.4% vs. 16.9%, p = 0.03). Overall long-term survival was similar in both groups in the Kaplan-Meier analysis. CONCLUSION Omitting ICAR during thoracoabdominal aortic replacement may reduce operation and cross-clamp times and thus minimize the duration of intraoperative spinal cord hypoperfusion.
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Affiliation(s)
- Florian Helms
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Reza Poyanmehr
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Heike Krüger
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Bastian Schmack
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Alexander Weymann
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Aron-Frederik Popov
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Arjang Ruhparwar
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Andreas Martens
- Clinic for Cardiac Surgery, University Clinic Oldenburg, 26133 Oldenburg, Germany
| | - Ruslan Natanov
- Clinic for Cardiac Surgery, University Clinic Oldenburg, 26133 Oldenburg, Germany
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von Aspern K, Haunschild J, Garbade J, Etz CD. Near-Infrared Spectroscopy for Spinal Cord Monitoring-A Roadmap to Translational Research in Aortic Medicine. AORTA (STAMFORD, CONN.) 2023; 11:145-151. [PMID: 37949108 PMCID: PMC11038735 DOI: 10.1055/s-0043-1772774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 07/19/2023] [Indexed: 11/12/2023]
Abstract
Extensive aortic aneurysms represent a unique challenge necessitating interdisciplinary efforts for safe and effective treatment. Despite various adjunctive neuroprotective strategies, ischemic spinal cord injury remains a devastating complication. This article describes the implementation of collateral network near-infrared spectroscopy as the first noninvasive spinal cord monitoring modality in the setting of extensive open and endovascular aortic repair, from early conceptualization to clinical utilization. Potential capabilities and remaining uncertainties based on current evidence are outlined and discussed.
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Affiliation(s)
| | - Josephina Haunschild
- Leipzig Heart Center, University Department for Cardiac Surgery, Leipzig, Saxony, Germany
| | - Jens Garbade
- Department for Cardiothoracic Surgery, Klinikum Links der Weser, Bremen, Germany
| | - Christian D. Etz
- Leipzig Heart Center, University Department for Cardiac Surgery, Leipzig, Saxony, Germany
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3
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Results of open thoracoabdominal aneurysm repair with left partial cardiopulmonary bypass in a low-volume center. ANGIOLOGIA 2022. [DOI: 10.20960/angiologia.00400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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4
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Simon MV, Dong CC, Jacobs MJ, Mess WH. Neuromonitoring during descending aorta procedures. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:407-431. [PMID: 35772899 DOI: 10.1016/b978-0-12-819826-1.00010-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Thoraco-abdominal aneurysm (TAA) repair carries a significant risk of spinal cord infarction. The latter results from irreversible changes in the spinal cord arterial network, e.g., sacrifice of the segmental arteries. Intra-operative neurophysiology with somatosensory and especially motor evoked potential (SEP and MEP respectively) monitoring, has emerged as an effective tool to assess the efficiency of the collateral blood flow, detect reversible spinal cord ischemia and guide the peri-operative multidisciplinary management to prevent postoperative paraplegia. The main roles of such monitoring include diagnosis of spinal cord vs peripheral limb ischemia, titration of mean arterial pressure during aortic clamping, the guidance of selective re-implantation of critical segmental arteries, and management of hemodynamics in the immediate postoperative period. In addition, manipulation of the aortic arch and proximal descending aorta, adds the risk of cerebral infarction from both low flow state and/or thromboembolic events. As such, EEG monitoring may be a useful add-on for either assessment of the efficiency of cerebral cooling as a neuroprotective method and/or for detection and treatment of reversible cerebral ischemia. This chapter presents the multimodality approach to open TAA monitoring as a versatile tool for the prevention of devastating postoperative neurologic deficits.
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Affiliation(s)
- Mirela V Simon
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States.
| | - Charles C Dong
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Michael J Jacobs
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Werner H Mess
- Department of Clinical Neurophysiology, Maastricht University Medical Center, Maastricht, The Netherlands
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5
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Mohebali J, Latz CA, Cambria RP, Patel VI, Ergul EA, Lancaster RT, Conrad MF, Clouse WD. The Long-term Fate of Renal and Visceral Vessel Reconstruction After Open Thoracoabdominal Aortic Aneurysm Repair. J Vasc Surg 2021; 74:1825-1832. [PMID: 34171425 DOI: 10.1016/j.jvs.2021.05.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES In the ever-advancing era of endovascular thoracoabdominal aneurysm (TAAA) repair, understanding long-term patency of renovisceral reconstructions after open TAAA repair provides important benchmarks. METHODS Institutional open TAAA repair patient data were queried. Patients dying during index admission or with incomplete operative detail were excluded. Visceral and renal reconstructions were categorized as bypass, incorporation into a proximal or distal beveled aortic anastomosis, inclusion button, Carrel patch, or hybrid stent along with endarterectomy/stent adjuncts. Axial imaging or angiography determined long-term patency. Vessel event was defined as new occlusion or reintervention after repair. Overall time-to-event analysis was performed as well as separate analyses for each vessel (Celiac, SMA, right renal, left renal) by reconstruction type utilizing Kaplan-Meier methods. Log-rank testing was employed to compare reconstructive strategies. RESULTS Over 28-years, 604 repairs [Type I 106(18%), Type II 73(12%), Type III 195(32%), Type IV 230(38%)] were identified. Follow-up (median 500 days) was available in 410/570(72%) Celiac, 406/573(71%) SMA, 379/532(71.2%) right renal, and 370/515(72%) left renal reconstructions. There were five celiac, one SMA, eight right renal, and ten left renal events. No type of reconstruction or adjunct was significantly associated with event. Overall 5-year patency of all renal/visceral reconstructions was 94% (95%CI [90%-96%]). Estimated 5-year patency of the Celiac, SMA, left renal, and right renal were similar, and were 99%, 100%, 97%, and 96%, respectively (p = .09). CONCLUSIONS Visceral and renal long-term patency after open TAAA repair is excellent regardless of reconstructive technique. No differences are appreciated even when target vessel disease is addressed at the time of reconstruction. These findings continue to substantiate the effective long-term durability of open TAAA repair and are particularly germane to the ongoing evolution of endovascular strategies.
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Affiliation(s)
- Jahan Mohebali
- Massachusetts General Hospital Division of Vascular and Endovascular Surgery, Harvard Medical School, Boston, MA
| | - Christopher A Latz
- Massachusetts General Hospital Division of Vascular and Endovascular Surgery, Harvard Medical School, Boston, MA
| | - Richard P Cambria
- Divison of Vascular Surgery, Steward Medical Group, St. Elizabeth's Medical Center, Brighton, MA
| | - Virendra I Patel
- Divison of Vascular Surgery and Endovascular Interventions, Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY
| | - Emel A Ergul
- Massachusetts General Hospital Division of Vascular and Endovascular Surgery, Harvard Medical School, Boston, MA
| | - R Todd Lancaster
- Massachusetts General Hospital Division of Vascular and Endovascular Surgery, Harvard Medical School, Boston, MA
| | - Mark F Conrad
- Massachusetts General Hospital Division of Vascular and Endovascular Surgery, Harvard Medical School, Boston, MA
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
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6
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Haunschild J, Khachatryan Z, von Aspern K, Herajärvi J, Ossmann S, Naumann J, Borger MA, Etz CD. Effect of cerebrospinal fluid pressure elevation on spinal cord perfusion during aortic cross-clamping with distal aortic perfusion. Eur J Cardiothorac Surg 2021; 60:569-576. [PMID: 33839764 DOI: 10.1093/ejcts/ezab167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/29/2021] [Accepted: 02/28/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Distal aortic perfusion (DaP) is a widely accepted protective adjunct facilitating early reinstitution of visceral perfusion during extended thoracic and thoraco-abdominal aortic repair. DaP has also been suggested to secure distal inflow to the paraspinal collateral network via the hypogastric arteries and thereby reduce the risk of spinal cord ischaemia. However, an increase in cerebrospinal fluid (CSF) pressure is frequently observed during thoracoabdominal aortic aneurysm repair. The aim of this study was to evaluate the effects of DaP on regional spinal cord blood flow (SCBF) during descending aortic cross-clamping and iatrogenic elevation of cerebrospinal fluid pressure. METHODS Eight juvenile pigs underwent central cannulation for cardiopulmonary bypass according to our established experimental protocol followed by aortic cross-clamping of the descending thoracic and abdominal aorta-mimicking sequential aortic clamping-with the initiation of DaP. Thereafter, CSF pressure elevation was induced by the infusion of blood plasma until baseline CSF pressure was tripled. At each time-point, microspheres of different colours were injected allowing for regional SCBF analysis. RESULTS DaP led to a pronounced hyperperfusion of the distal spinal cord [SCBF up to 480%, standard deviation (SD): 313%, compared to baseline]. However, DaP provided no or only limited additional flow to the upper and middle segments of the spinal cord (C1-Th7: 5% of baseline, SD: 5%; Th8-L2: 24%, SD: 39%), which was compensated by proximal flow only at C1-Th7 level. Furthermore, DaP could not counteract an experimental CSF pressure elevation, which led to a further decrease in regional SCBF most pronounced in the mid-thoracic spinal cord segment. CONCLUSIONS Protective DaP during thoraco-abdominal aortic repair may be associated with inadequate spinal protection particularly at the mid-thoracic spinal cord level ('watershed area') and result in the adverse effect of a potentially dangerous hyperperfusion of the distal spinal cord segments.
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Affiliation(s)
- Josephina Haunschild
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Heisenberg Working Group for Aortic Surgery, Saxonian Incubator for Clinical Translation (SIKT), University Leipzig, Leipzig, Germany
| | - Zara Khachatryan
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Heisenberg Working Group for Aortic Surgery, Saxonian Incubator for Clinical Translation (SIKT), University Leipzig, Leipzig, Germany
| | - Konstantin von Aspern
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Heisenberg Working Group for Aortic Surgery, Saxonian Incubator for Clinical Translation (SIKT), University Leipzig, Leipzig, Germany
| | - Johanna Herajärvi
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Heisenberg Working Group for Aortic Surgery, Saxonian Incubator for Clinical Translation (SIKT), University Leipzig, Leipzig, Germany
| | - Susann Ossmann
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Jörg Naumann
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Heisenberg Working Group for Aortic Surgery, Saxonian Incubator for Clinical Translation (SIKT), University Leipzig, Leipzig, Germany
| | - Michael A Borger
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Christian D Etz
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Heisenberg Working Group for Aortic Surgery, Saxonian Incubator for Clinical Translation (SIKT), University Leipzig, Leipzig, Germany
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7
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Neurologic complications of diseases of the aorta. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:221-239. [PMID: 33632441 DOI: 10.1016/b978-0-12-819814-8.00028-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Neurologic complications of diseases of the aorta are common, as the brain and spinal cord function is highly dependent on the aorta and its branches for blood supply. Any disease impacting the aorta may have significant impact on the ability to deliver oxygenated blood to the central nervous system, resulting in ischemia-and if prolonged-cerebral and spinal infarct. The breadth of pathology affecting the aorta is diverse and neurologic complications can vary dramatically based on the location, severity, and underlying etiology. This chapter outlines the major pathology of the aorta while highlighting the associated neurologic complications. This chapter covers the entire spectrum of neurologic complications associated with aortic disease by beginning with a detailed overview of the spinal cord vascular anatomy followed by a discussion of the most common aortic pathologies affecting the nervous system, including aortic aneurysm, aortic dissection, aortic atherosclerosis, inflammatory and infectious aortopathies, congenital abnormalities, and aortic surgery.
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8
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Mehmedovic A, Konstantinou N, Jerkku T, Pichlmaier M, Kölbel T, Rantner B, Banafsche R, Tsilimparis N. [Aortic Aneurysm: Fenestrated/Branched Endovascular Aortic Repair (EVAR) and Fenestrated/Branched Thoracic Endovascular Aortic Repair (TEVAR). Is Total Endovascular Repair Already Here?]. Zentralbl Chir 2020; 145:432-437. [PMID: 32659798 DOI: 10.1055/a-1186-2554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Five years after the first endovascular aortic repair (EVAR), Park et al. reported the first implantation of a fenestrated endoprosthesis. In the meantime, advanced generations of new fenestrated and branched endografts evolved. Endografts for complex pathologies are either so-called "off-the-shelf" grafts with predetermined length, width, diameter and clock position of the branches and fenestrations, predetermined by the manufacturer, "custom-made" grafts which need to be sized and planned individually for patients with specific thoracoabdominal anatomy. Open aortic repair in the treatment of thoracoabdominal aortic aneurysm (TAAA) still remains challenging and is associated with high morbidity and mortality, even in the elective setting. The ongoing development of endovascular treatment modalities, such as fenestrated and branched endovascular aneurysm repair (F-EVAR, B-EVAR), enables less invasive procedures for more challenging aortic pathologies. In recent years, extensive endovascular treatment of the aortic arch to the thoracoabdominal segment has become more and more important, but its outcomes have not been completely evaluated. The aim of this is article is to provide an overview of the currently available endovascular treatment options for complex aortic aneurysms requiring extensive coverage from the aortic arch to the infrarenal aorta.
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Affiliation(s)
- Aldin Mehmedovic
- Abteilung für Gefäßchirurgie - Vaskuläre und Endovaskuläre Chirurgie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - Nikolaos Konstantinou
- Abteilung für Gefäßchirurgie - Vaskuläre und Endovaskuläre Chirurgie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - Thomas Jerkku
- Abteilung für Gefäßchirurgie - Vaskuläre und Endovaskuläre Chirurgie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - Maximilian Pichlmaier
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - Tilo Kölbel
- Klinik und Poliklinik für Gefäßmedizin, Universitäres Herzzentrum Hamburg-Eppendorf, Deutschland
| | - Barbara Rantner
- Abteilung für Gefäßchirurgie - Vaskuläre und Endovaskuläre Chirurgie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - Ramin Banafsche
- Abteilung für Gefäßchirurgie - Vaskuläre und Endovaskuläre Chirurgie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - Nikolaos Tsilimparis
- Abteilung für Gefäßchirurgie - Vaskuläre und Endovaskuläre Chirurgie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
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Tsilimparis N, Haulon S, Spanos K, Rohlffs F, Heidemann F, Resch T, Dias N, Kölbel T. Combined fenestrated-branched endovascular repair of the aortic arch and the thoracoabdominal aorta. J Vasc Surg 2020; 71:1825-1833. [DOI: 10.1016/j.jvs.2019.08.261] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 08/16/2019] [Indexed: 11/17/2022]
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10
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Papanikolaou D, Savio C, Zafar MA, Freudzon L, Wu J, Abdelbaky M, Pelletier KJ, Buntin J, Faggion Vinholo T, Ziganshin BA, Schwartz B, Elefteriades JA. Left Atrial to Femoral Artery Full Cardiopulmonary Bypass: A Novel Technique for Descending and Thoracoabdominal Aortic Surgery. Int J Angiol 2020; 29:19-26. [PMID: 32132812 PMCID: PMC7054066 DOI: 10.1055/s-0039-3400479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Left atrial-femoral artery (LA-FA) bypass with a centrifugal pump and no oxygenator is commonly used for descending and thoracoabdominal aortic (DTAA) operations, mitigating the deleterious effects of cross-clamping. We present our initial experience performing DTAA replacement under LA-FA (left-to-left) cardiopulmonary bypass (CPB) with an oxygenator. DTAA replacement under LA-FA bypass with an oxygenator was performed in 14 consecutive patients (CPB group). The pulmonary vein and femoral artery (or distal aorta) were cannulated and the full CPB machine were used, including oxygenator, roller pump, pump suckers, and kinetically enhanced drainage. The CPB group was compared with 50 consecutive patients who underwent DTAA replacement utilizing traditional LA-FA bypass without an oxygenator (LA-FA group). Perioperative data were collected and statistical analyses were performed. All CPB patients maintained superb cardiopulmonary stability. The pump sucker permitted immediate salvage and return of shed blood. Superb oxygenation was maintained at all times. High-dose full CPB heparin was reversed without difficulty. The CPB group required markedly fewer blood transfusions than the LA-FA group (2.21 vs. 5.88 units, p < 0.004). The 30-day mortality rate was 7.1% ( n = 1) and there were no paraplegia cases in the CPB group versus 7 (14%) deaths and 3 (6%) paraplegia cases in the LA-FA group. Traditional LA-FA bypass without an oxygenator avoids high-dose heparin. In the present era, heparin reversal is more secure. Our experience finds that the novel application of LA-FA CPB with an oxygenator is safe and suggests improved hemodynamics (immediate return of shed blood) and a hemostatic advantage (avoidance of loss of coagulation factors in the cell saver).
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Affiliation(s)
- Dimitra Papanikolaou
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Chris Savio
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Mohammad A. Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Leon Freudzon
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Jinlin Wu
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Mohamed Abdelbaky
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Keith J. Pelletier
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Joelle Buntin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Thais Faggion Vinholo
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Bulat A. Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
- Department of Surgical Diseases, Kazan State Medical University, Kazan, Russia
| | - Brian Schwartz
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - John A. Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
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Shimamura J, Oshima S, Ozaki K, Sakurai S, Hirai Y, Hirokami T, Fujikawa T, Ozaki A, Yamamoto S. Open Thoracoabdominal Aortic Aneurysm Repair: Contemporary Outcomes for 393 Elective Cases. Ann Thorac Surg 2019; 107:1326-1332. [DOI: 10.1016/j.athoracsur.2018.11.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 10/14/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
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12
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Walker J, Kaushik S, Hoffman M, Gasper W, Hiramoto J, Reilly L, Chuter T. Long-term durability of multibranched endovascular repair of thoracoabdominal and pararenal aortic aneurysms. J Vasc Surg 2019; 69:341-347. [PMID: 30683193 DOI: 10.1016/j.jvs.2018.04.074] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/09/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The objective of this study was to assess the durability of multibranched endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms by examining the rates of late-occurring (beyond 30 days) complications. METHODS There were 146 patients who underwent endovascular TAAA repair using a stent graft, with a total of 538 caudally oriented self-expanding branches. Four patients died in the perioperative period and were excluded, leaving 142 patients (mean age, 73 ± 8 years; 35 [24.7%] women). Follow-up included clinical examination and computed tomography angiography at 1 month, 6 months, and 12 months and yearly thereafter. RESULTS Mean aneurysm diameter was 67 ± 9 mm. Sixty-seven TAAAs (47.2%) were Crawford type I, II, III, or V; 75 (52.8%) were type IV or pararenal. Three patients (2.1%) died >30 days after operation from perioperative complications. During a mean follow-up of 36 months (±28 months), there were four additional aneurysm-related deaths: one (0.7%) as a result of aneurysm rupture in the presence of untreatable type I endoleak, one (0.7%) after conversion to open repair for stent graft infection, one (0.7%) after occlusion of superior mesenteric artery and celiac branches, and one (0.7%) due to bilateral renal branch occlusion. There was one additional open conversion for stent graft infection (0.7%). Nineteen patients (13.3%) underwent 20 reinterventions for late-occurring complications, including 11 (7.7%) for renal branch occlusion or stenosis, 1 (0.7%) for mesenteric branch stenosis, 4 (2.8%) for graft limb occlusion, 1 (0.7%) for type IB endoleak (distal stent graft migration), and 1 (0.7%) for type III endoleak (fabric erosion); 2 (1.4%) open conversions were performed for stent graft infection. There were no late type IA endoleaks. By Kaplan-Meier analysis, freedom from aneurysm-related death was 91.1% and freedom from aneurysm-related death or reintervention was 76.8% at 5 years. The 5-year overall survival rate of 49.1% reflects the high rate of cardiopulmonary comorbidity. Although renal branch occlusion (23 occlusions of 256 renal branches [8.9%]) was the most common late complication, only five patients required permanent dialysis. CONCLUSIONS Total endovascular repair of TAAAs and pararenal aortic aneurysms using axially oriented cuffs is safe, effective, and durable in the long term.
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Affiliation(s)
- Joy Walker
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
| | - Smita Kaushik
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Megan Hoffman
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Warren Gasper
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Jade Hiramoto
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Linda Reilly
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Timothy Chuter
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
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13
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Spanos K, Kölbel T, Kubitz JC, Wipper S, Konstantinou N, Heidemann F, Rohlffs F, Debus SE, Tsilimparis N. Risk of spinal cord ischemia after fenestrated or branched endovascular repair of complex aortic aneurysms. J Vasc Surg 2018; 69:357-366. [PMID: 30385148 DOI: 10.1016/j.jvs.2018.05.216] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 05/14/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of our study was to analyze the incidence of spinal cord ischemia (SCI) in patients presenting with complex aortic aneurysms treated with endovascular aneurysm repair (EVAR) and to identify risk factors associated with this complication. METHODS A retrospective study was undertaken of prospectively collected data including patients presenting with complex aortic aneurysm (pararenal abdominal aortic aneurysm and thoracoabdominal aortic aneurysm) treated with fenestrated EVAR (F-EVAR) or branched EVAR (B-EVAR). The primary end point was the incidence of SCI and the assessment of any associated factors. RESULTS Between January 2011 and August 2017, a total of 243 patients (mean aneurysm diameter, 65.2 ± 15.3 mm; mean age, 72.4 ± 7.5 years; 73% male) were treated with F-EVAR or B-EVAR. Asymptomatic patients were treated in 73% of the cases (177/243, in contrast to 27% urgent), and 52% (126/243) were treated for thoracoabdominal aortic aneurysm (in contrast to 48% for pararenal abdominal aortic aneurysm). F-EVAR (mean number of fenestrations, 3.3/case) and B-EVAR (mean number of branches, 3.7/case) were undertaken in 67% (164/243) and 33% (79/243), respectively. The total incidence of SCI was 17.7% [43/243; paraplegia in 4% (10/243) and paraparesis in 13.7% (33/243)]. Most of the patients with SCI presented with immediate postoperative symptoms (72% [31/43]). A spinal drain was preoperatively placed in 53% (130/243) and was associated with the prevention of SCI (SCI with spinal drainage, 12% [16/130]; SCI without spinal drainage, 24% [27/113]; P = .018). The 30-day mortality rate was 9% (21/243). After multiple logistic regression analysis, SCI was associated with preoperative renal function (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m2: odds ratio [OR], 2.43; 95% confidence interval [CI], 1.18-4.99; P = .016) and the number of vertebral segments covered (SCI with higher position of proximal stent in terms of vertebra: OR, 1.2; 95% CI, 1.1-1.3; P = .000). A similar outcome was derived when the height of the proximal end of the stent graft was replaced by the total length of aortic coverage (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m2: OR, 2.36 [95% CI, 1.11-5.00; P = .025]; SCI with longer length of aortic coverage: OR, 1.01 [95% CI, 1.003-1.009; P = .000]). CONCLUSIONS The majority of SCI incidence after F-EVAR or B-EVAR of complex aortic aneurysms is manifested immediately postoperatively. The use of preoperative spinal drainage may prevent SCI. Patients with GRF <60 mL/min/1.73 m2 and with longer aortic stent graft coverage are at higher risk of SCI.
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Affiliation(s)
- Konstantinos Spanos
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany.
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany
| | - Jens C Kubitz
- Department of Anesthesiology, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany
| | - Sabine Wipper
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany
| | - Nikolaos Konstantinou
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany
| | - Franziska Heidemann
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany
| | - Fiona Rohlffs
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany
| | - Sebastian E Debus
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany
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Mohebali J, Carvalho S, Lancaster RT, Ergul EA, Conrad MF, Clouse WD, Cambria RP, Patel VI. Use of extracorporeal bypass is associated with improved outcomes in open thoracic and thoracoabdominal aortic aneurysm repair. J Vasc Surg 2018; 68:941-947. [DOI: 10.1016/j.jvs.2017.12.072] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 12/21/2017] [Indexed: 11/26/2022]
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15
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Kolvenbach RR. Contemporary strategies for repair of complex thoracoabdominal aortic aneurysms: real-world experiences and multilayer stents as an alternative. J Vasc Bras 2017; 16:293-303. [PMID: 29930663 PMCID: PMC5944306 DOI: 10.1590/1677-5449.011417] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Thoracoabdominal aortic aneurysms (TAAA) present special challenges for repair due to their extent, their distinctive pathology, and the fact that they typically cross the ostia of one or more visceral branch vessels. Historically, the established treatment for TAAA was open surgical repair, with the first procedure reported in 1955. Endovascular repair of TAAA with fenestrated and/ or branched endografts, has been studied since the beginning of the current century as a means of mechanical aneurysm exclusion. More recently, flow modulator stents have been employed with the aim at reducing shear stress on aortic aneurysmal wall. In this review we present technical and main results of these techniques, based on literature review and personal experience.
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Affiliation(s)
- Ralf Robert Kolvenbach
- Catholic Hospital Group Duesseldorf, Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital, Duesseldorf, Germany
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Foley LS, Fullerton DA, Mares J, Sungelo M, Weyant MJ, Cleveland JC, Reece TB. Erythropoietin's Beta Common Receptor Mediates Neuroprotection in Spinal Cord Neurons. Ann Thorac Surg 2017; 104:1909-1914. [PMID: 29100648 DOI: 10.1016/j.athoracsur.2017.07.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 07/11/2017] [Accepted: 07/20/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Paraplegia from spinal cord ischemia-reperfusion (SCIR) remains an elusive and devastating complication of complex aortic operations. Erythropoietin (EPO) attenuates this injury in models of SCIR. Upregulation of the EPO beta common receptor (βcR) is associated with reduced damage in models of neural injury. The purpose of this study was to examine whether EPO-mediated neuroprotection was dependent on βcR expression. We hypothesized that spinal cord neurons subjected to oxygen-glucose deprivation would mimic SCIR injury in aortic surgery and EPO treatment attenuates this injury in a βcR-dependent fashion. METHODS Lentiviral vectors with βcR knockdown sequences were tested on neuron cell cultures. The virus with greatest βcR knockdown was selected. Spinal cord neurons from perinatal wild-type mice were harvested and cultured to maturity. They were treated with knockdown or nonsense virus and transduced cells were selected. Three groups (βcR knockdown virus, nonsense control virus, no virus control; n = 8 each) were subjected to 1 hour of oxygen-glucose deprivation. Viability was assessed. βcR expression was quantified by immunoblot. RESULTS EPO preserved neuronal viability after oxygen-glucose deprivation (0.82 ± 0.04 versus 0.61 ± 0.01; p < 0.01). Additionally, EPO-mediated neuron preservation was similar in the nonsense virus and control mice (0.82 ± 0.04 versus 0.80 ± 0.05; p = 0.77). EPO neuron preservation was lost in βcR knockdown mice compared with nonsense control mice (0.46 ± 0.03 versus 0.80 ± 0.05; p < 0.01). CONCLUSIONS EPO attenuates neuronal loss after oxygen-glucose deprivation in a βcR-dependent fashion. This receptor holds immense clinical promise as a target for pharmacotherapies treating spinal cord ischemic injury.
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Affiliation(s)
- Lisa S Foley
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Denver, Aurora, Colorado.
| | - David A Fullerton
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Denver, Aurora, Colorado
| | - Joshua Mares
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Denver, Aurora, Colorado
| | - Mitchell Sungelo
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Denver, Aurora, Colorado
| | - Michael J Weyant
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Denver, Aurora, Colorado
| | - Joseph C Cleveland
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Denver, Aurora, Colorado
| | - T Brett Reece
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Denver, Aurora, Colorado
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Systematic review of motor evoked potentials monitoring during thoracic and thoracoabdominal aortic aneurysm open repair surgery: a diagnostic meta-analysis. J Anesth 2016; 30:1037-1050. [DOI: 10.1007/s00540-016-2242-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 08/15/2016] [Indexed: 10/21/2022]
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19
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Wynn M, Acher C, Marks E, Acher C. The effect of intercostal artery reimplantation on spinal cord injury in thoracoabdominal aortic aneurysm surgery. J Vasc Surg 2016; 64:289-296. [DOI: 10.1016/j.jvs.2015.12.060] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 12/30/2015] [Indexed: 10/22/2022]
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20
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Acher C, Acher C, Marks E, Wynn M. Intraoperative neuroprotective interventions prevent spinal cord ischemia and injury in thoracic endovascular aortic repair. J Vasc Surg 2016; 63:1458-65. [DOI: 10.1016/j.jvs.2015.12.062] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 12/30/2015] [Indexed: 11/16/2022]
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21
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Aorta-Iliac Bypass in Thoracoabdominal Aortic Aneurysm Repair in Young Chinese Patients. Heart Lung Circ 2016; 25:398-404. [DOI: 10.1016/j.hlc.2015.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 08/17/2015] [Accepted: 08/31/2015] [Indexed: 11/23/2022]
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Sivaraman S, Harris D, Bhardwaj A, Steiner G, Magarakis M, Sarkar R, Crawford R, Toursavadkohi S. Application of a Hybrid Vascular Graft for Rapid Endoluminal Branch Anastomoses During Open Aortic Reconstruction. Vasc Endovascular Surg 2016; 50:160-3. [PMID: 26993592 DOI: 10.1177/1538574416637444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The treatment of thoracoabdominal aneurysms and juxtarenal aortic aneurysms remains technically challenging, with outcomes primarily dictated by aortic cross-clamp and end-organ ischemia during branch reconstruction. This has remained a challenge for the surgeon regardless of an elective setting or an emergent operation. Here we describe the application of a novel hybrid graft technique for aortic branch reconstruction using rapid, endoluminal anastomoses during open aortic reconstruction.
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Affiliation(s)
- Srikant Sivaraman
- Division of Vascular Surgery, Department of General Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Donald Harris
- Division of Vascular Surgery, Department of General Surgery, University of Maryland School of Medicine, Baltimore, MD, USA Division of Vascular Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Abhishek Bhardwaj
- Division of Vascular Surgery, Department of General Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gregory Steiner
- Department of Surgery, Union Memorial Hospital, Baltimore, MD, USA
| | - Michael Magarakis
- Division of Vascular Surgery, Department of General Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rajabrata Sarkar
- Surgery, University of Maryland, Baltimore, MD, USA Center for Aortic Disease, University of Maryland Medical Centre, Baltimore, MD, USA
| | - Robert Crawford
- Division of Vascular Surgery, Department of General Surgery, University of Maryland School of Medicine, Baltimore, MD, USA Center for Aortic Disease, University of Maryland Medical Centre, Baltimore, MD, USA
| | - Shahab Toursavadkohi
- Division of Vascular Surgery, Department of General Surgery, University of Maryland School of Medicine, Baltimore, MD, USA Center for Aortic Disease, University of Maryland Medical Centre, Baltimore, MD, USA
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See RB, Awosika OO, Cambria RP, Conrad MF, Lancaster RT, Patel VI, Chitilian HV, Kumar S, Simon MV. Extended Motor Evoked Potentials Monitoring Helps Prevent Delayed Paraplegia After Aortic Surgery. Ann Neurol 2016; 79:636-45. [PMID: 26841128 DOI: 10.1002/ana.24610] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 02/01/2016] [Accepted: 02/01/2016] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Motor evoked potentials (MEPs) monitoring can promptly detect spinal cord ischemia (SCI) from aortic clamping during open thoracoabdominal aneurysm repair (OTAAR) with distal aortic perfusion (DAP) and thus help decrease the risk of immediate postoperative SCI (IP-SCI). However, neither stable MEPs during aortic clamp interval (ACI) nor absence of IP-SCI eliminate the possibility of delayed postoperative SCI (DP-SCI). We hypothesized that extension of MEPs monitoring beyond ACI can also help decrease the risk of DP-SCI. METHODS We identified 150 consecutive patients at our institution between April 2005 and October 2014 who underwent OTAAR with DAP and MEPs monitoring and had no IP-SCI. Using logistic regression analysis, we studied the independent effect of extended MEPs monitoring on the risk of developing DP-SCI. We used a propensity score analysis to adjust for potential confounders, such as poorly controlled hypertension, previous aneurysm surgery, splenectomy, acute aortic dissection, aneurysm type, older age, and history of diabetes and smoking. RESULTS From the 150 patients, 129 (86%) remained neurologically intact whereas 21 (14%) developed DP-SCI. Nineteen of these twenty-one patients (90%) had no extended monitoring. Fifty-seven of fifty-nine (97%) patients who benefited from extended monitoring had no DP-SCI (p = 0.003). Extended MEPs monitoring was independently associated with decreased risk of DP-SCI (odds ratio = 0.14; 95% confidence interval: 0.03, 0.65; p = 0.01). INTERPRETATION MEPs detect the lowest systemic blood pressure that ensures appropriate spinal cord perfusion in the postoperative period. Thus, they inform the hemodynamic management of patients post-OTAAR, particularly in the absence of a reliable neurological exam.
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Affiliation(s)
- Reiner B See
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Oluwole O Awosika
- Department of Neurology, Massachusetts General Hospital, Boston, MA.,National Institute of Neurological Disorders and Stroke/National Institutes of Health, Bethesda, MD
| | - Richard P Cambria
- Department of Vascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Mark F Conrad
- Department of Vascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Robert T Lancaster
- Department of Vascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Virendra I Patel
- Department of Vascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Hovig V Chitilian
- Department of Anesthesia, Massachusetts General Hospital, Boston, MA
| | - Sandeep Kumar
- Department of Neurology, Beth Israel Deaconess Center, Boston, MA
| | - Mirela V Simon
- Department of Neurology, Massachusetts General Hospital, Boston, MA
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Schepens MAAM. Left heart bypass for thoracoabdominal aortic aneurysm repair: technical aspects. Multimed Man Cardiothorac Surg 2016; 2016:mmv039. [PMID: 26825797 DOI: 10.1093/mmcts/mmv039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 12/12/2015] [Indexed: 11/12/2022]
Abstract
There are different surgical techniques for providing circulatory support during the repair of thoracoabdominal aortic aneurysms. They all aim at reducing the afterload of the heart and the preservation of distal organ perfusion. Partial or total extracorporeal circulation with or without cooling and left heart bypass (LHB) are actually the most used surgical approaches. The objective of this study was to describe and comment on the technical aspects of the LHB. We briefly describe our results and put them into perspective based on the current literature.
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Katsargyris A, Oikonomou K, Kouvelos G, Renner H, Ritter W, Verhoeven EL. Spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms with fenestrated and branched stent grafts. J Vasc Surg 2015; 62:1450-6. [DOI: 10.1016/j.jvs.2015.07.066] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 07/07/2015] [Indexed: 11/16/2022]
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Espinosa G, Tavares R, Fonseca F, Collares A, Lopes M, Fonseca JL, Steffan R. Proximal endovascular blood flow shunt for thoracoabdominal aortic aneurism without total aortic clamping. Rev Col Bras Cir 2015; 42:189-92. [PMID: 26291261 DOI: 10.1590/0100-69912015003011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 04/15/2014] [Indexed: 11/22/2022] Open
Abstract
The authors present a surgical approach to type III and IV Crawford aneurysms that does not need total aortic clamping, which allows the more objective prevention of direct ischemic damage, as well as its exclusion by the endoprosthesis implantation, shunting the flow to the synthetic graft.
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Affiliation(s)
- Gaudencio Espinosa
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, RJ, BR
| | - Rivaldo Tavares
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, RJ, BR
| | - Felippe Fonseca
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, RJ, BR
| | - Alessandra Collares
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, RJ, BR
| | - Marina Lopes
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, RJ, BR
| | - Jose Luis Fonseca
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, RJ, BR
| | - Rafael Steffan
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, RJ, BR
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Spinal Cord Ischemia-Reperfusion Injury Induces Erythropoietin Receptor Expression. Ann Thorac Surg 2015; 100:41-6; discussion 46. [DOI: 10.1016/j.athoracsur.2015.01.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 01/02/2015] [Accepted: 01/06/2015] [Indexed: 01/22/2023]
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Sobel JD, Vartanian SM, Gasper WJ, Hiramoto JS, Chuter TA, Reilly LM. Lower extremity weakness after endovascular aneurysm repair with multibranched thoracoabdominal stent grafts. J Vasc Surg 2015; 61:623-8. [DOI: 10.1016/j.jvs.2014.10.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 10/09/2014] [Indexed: 11/24/2022]
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Panthee N, Ono M. Spinal cord injury following thoracic and thoracoabdominal aortic repairs. Asian Cardiovasc Thorac Ann 2015; 23:235-246. [DOI: 10.1177/0218492314548901] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Objective To discuss the currently available approaches to prevent spinal cord injury during thoracic and thoracoabdominal aortic repairs. Methods We carried out a PubMed search up to 2013 using the Medical Subject Headings: “aortic aneurysm/surgery” and “spinal cord ischemia”; “aortic aneurysm, thoracic/surgery” and “spinal cord ischemia”; “aneurysm/surgery” and “spinal cord ischemia/cerebrospinal fluid”; “aortic aneurysm/surgery” and “paraplegia”. All 190 original articles satisfying our inclusion criteria were analyzed for incidence, predictors, and other pertinent variables related to spinal cord injury, and we compared the results in recent publications with those in earlier reports. Results The mean age of the 38,491 patients was 65.3 ± 4.9 years. The overall incidence of paraplegia and/or paraparesis was 7.1% ± 6.1% (range 0%–32%). The incidence of spinal cord injury before 2000, from 2001 to 2007, and 2008–2013 was 9.0% ± 6.7%, 7.0% ± 6.1%, and 5.9% ± 5.2%, respectively ( p = 0.019). Various predictors of spinal cord injury were identified, extent of disease being the most common. Modification of surgical techniques, use of adjuncts, and better understanding of spinal cord perfusion physiology were attributed to the decrease in postoperative spinal cord injury in recent years. Conclusions Spinal cord injury after thoracic and thoracoabdominal aortic repair poses a real challenge to cardiovascular surgeons. However, with evolving surgical strategies, identification of predictors, and use of various adjuncts over the years, the incidence of spinal cord injury after thoracic/thoracoabdominal aortic repair has declined. Embracing a multimodality approach offers a good insight into combating this grave complication.
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Affiliation(s)
- Nirmal Panthee
- Department of Cardiac Surgery, University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, University of Tokyo, Tokyo, Japan
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Abstract
Thoracoabdominal aneurysm of the aorta (TAAA) is a morbid condition, the treatment of which can be associated with high mortality and complication rates, as well as prolonged length of hospital stay. Currently, three approaches to treatment of TAAAs exist: open, endovascular and hybrid repair. Over the past three decades, a significant decrease in postoperative mortality and paraplegia rates has been achieved due to effective application of such treatment adjuncts as left heart bypass, cerebrospinal fluid drainage, application of hypothermia and neuromonitoring, thereby making surgical treatment of TAAAs increasingly safer for the patient. In this report, we review indications and current approaches to surgical management of TAAAs, as well as the factors that influence the efficacy of this type of treatment.
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Kato M, Motoki M, Isaji T, Suzuki T, Kawai Y, Ohkubo N. Spinal cord injury after endovascular treatment for thoracoabdominal aneurysm or dissection. Eur J Cardiothorac Surg 2014; 48:571-7. [DOI: 10.1093/ejcts/ezu497] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 11/13/2014] [Indexed: 11/13/2022] Open
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Wynn MM, Acher C. A Modern Theory of Spinal Cord Ischemia/Injury in Thoracoabdominal Aortic Surgery and Its Implications for Prevention of Paralysis. J Cardiothorac Vasc Anesth 2014; 28:1088-99. [DOI: 10.1053/j.jvca.2013.12.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Indexed: 11/11/2022]
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Xu J, Huang G, Zhang K, Sun J, Xu T, Li R, Tao H, Xu W. Nrf2 activation in astrocytes contributes to spinal cord ischemic tolerance induced by hyperbaric oxygen preconditioning. J Neurotrauma 2014; 31:1343-53. [PMID: 24716787 DOI: 10.1089/neu.2013.3222] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
In this study, we investigated whether nuclear factor erythroid 2-related factor 2 (Nrf2) activation in astrocytes contributes to the neuroprotection induced by a single hyperbaric oxygen preconditioning (HBO-PC) against spinal cord ischemia/reperfusion (SCIR) injury. In vivo: At 24 h after a single HBO-PC at 2.5 atmospheres absolute for 90 min, the male ICR mice underwent SCIR injury by aortic cross-clamping surgery and observed for 48 h. HBO-PC significantly improved hindlimb motor function, reduced secondary spinal cord edema, ameliorated the reactivity of spinal motor-evoked potentials, and slowed down the process of apoptosis to exert neuroprotective effects against SCIR injury. At 12 h or 24 h after HBO-PC without aortic cross-clamping surgery, Western blot, enzyme-linked immunosorbent assay, realtime-polymerase chain reaction and double-immunofluorescence staining were used to detect the Nrf2 activity of spinal cord tissue, such as mRNA level, protein content, DNA binding activity, and the expression of downstream gene, such as glutamate-cysteine ligase, γ-glutamyltransferase, multidrug resistance protein 1, which are key proteins for intracellular glutathione synthesis and transit. The Nrf2 activity and downstream genes expression were all enhanced in normal spinal cord with HBO-PC. Glutathione content of spinal cord tissue with HBO-PC significantly increased at all time points after SCIR injury. Moreover, Nrf2 overexpression mainly occurs in astrocytes. In vitro: At 24 h after HBO-PC, the primary spinal astrocyte-neuron co-cultures from ICR mouse pups were subjected to oxygen-glucose deprivation (OGD) for 90 min to simulate the ischemia-reperfusion injury. HBO-PC significantly increased the survival rate of neurons and the glutathione content in culture medium, which was mainly released from asctrocytes. Moreover, the Nrf2 activity and downstream genes expression induced by HBO-PC were mainly enhanced in astrocytes, but not in neurons. In conclusion, our findings demonstrated that spinal cord ischemic tolerance induced by HBO-PC may be mainly related to Nrf2 activation in astrocytes.
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Affiliation(s)
- Jiajun Xu
- 1 Department of Diving and Hyperbaric Medicine, College of Naval Medicine, the Second Military Medical University , Shanghai, China
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Hershberger R, Cho JS. Neurologic complications of aortic diseases and aortic surgery. HANDBOOK OF CLINICAL NEUROLOGY 2014; 119:223-238. [PMID: 24365299 DOI: 10.1016/b978-0-7020-4086-3.00016-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Aortic disease processes have a wide range of clinical manifestations. The inflammatory disease process of Takayasu's arteritis differs dramatically from the visceral ischemia of aortic dissection. The catastrophic event of aortic rupture tends to overshadow life-altering events such as stroke and paraplegia. However, these neurologic manifestations of aortic diseases have dramatic effects that extend beyond the individual patient to include both social and financial ramifications. This chapter focuses on the major aortic disease processes and how they can initiate, both directly and indirectly, adverse neurologic events. The chapter concludes with a brief discussion of aortic surgery, how interventions on the aorta can cause neurologic complications, and techniques to avoid these feared adverse neurologic outcomes.
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Affiliation(s)
- Richard Hershberger
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA.
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
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Saito Y, Taniguchi S, Watanabe K, Fukui K, Fukuda I. Bilateral axillary arterial aneurysms in siblings with Marfan syndrome. Ann Vasc Surg 2014; 28:740.e13-6. [PMID: 24378247 DOI: 10.1016/j.avsg.2013.06.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2012] [Revised: 05/15/2013] [Accepted: 06/04/2013] [Indexed: 10/25/2022]
Abstract
Axillary arterial aneurysm associated with Marfan syndrome is an extremely rare and dangerous disease because of its potential risk for rupture and impairment of neurologic function in the upper extremities. Treatment of large axillary aneurysms can be surgically challenging because the axillary artery is anatomically located under the clavicle bones and the brachial plexus runs dorsal to the aneurysm. We report 2 cases of bilateral axillary arterial aneurysms in brothers with Marfan syndrome. Revival of a novel approach and cautious attempts during the procedures are described in both cases.
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Affiliation(s)
- Yoshiaki Saito
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, Aomori, Japan
| | - Satoshi Taniguchi
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, Aomori, Japan
| | - Kenichi Watanabe
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, Aomori, Japan
| | - Kozo Fukui
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, Aomori, Japan
| | - Ikuo Fukuda
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, Aomori, Japan.
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Sloan TB, Edmonds HL, Koht A. Intraoperative Electrophysiologic Monitoring in Aortic Surgery. J Cardiothorac Vasc Anesth 2013; 27:1364-73. [DOI: 10.1053/j.jvca.2012.09.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2012] [Indexed: 11/11/2022]
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LeMaire SA, Price MD, Green SY, Zarda S, Coselli JS. Results of open thoracoabdominal aortic aneurysm repair. Ann Cardiothorac Surg 2013; 1:286-92. [PMID: 23977510 DOI: 10.3978/j.issn.2225-319x.2012.08.16] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 08/27/2012] [Indexed: 11/14/2022]
Abstract
BACKGROUND Open surgical repair of thoracoabdominal aortic aneurysms (TAAAs) enables the effective replacement of the diseased aortic segment and reliably prevents aneurysm rupture. However, these operations also carry substantial risk of perioperative morbidity and mortality, principally caused by the associated ischemic insult involving the spinal cord, kidneys, and other abdominal viscera. Here, we describe the early outcomes of a contemporary series of open TAAA repairs. METHODS We reviewed the outcomes of 823 open TAAA repairs performed between January 2005 and May 2012. Of these, 209 (25.4%) were Crawford extent I repairs, 264 (32.1%) were extent II, 157 (19.1%) were extent III, and 193 (23.5%) were extent IV. Aortic dissection was present in 350 (42.5%) cases, and aneurysm rupture was present in 37 (4.5%). Adjuncts used during the procedures included cerebrospinal fluid drainage in 639 (77.6%) cases, left heart bypass in 430 (52.2%), and cold renal perfusion in 674 (81.9%). RESULTS The composite endpoint, adverse outcome-defined as operative death, renal failure that necessitated dialysis at discharge, stroke, or permanent paraplegia or paraparesis-occurred after 131 (15.9%) procedures. There were 69 (8.4%) operative deaths. Permanent paraplegia or paraparesis occurred after 42 (5.1%) cases, stroke occurred after 27 (3.3%), and renal failure necessitating permanent dialysis occurred after 45 (5.5%). CONCLUSIONS Although open surgical repair of the thoracoabdominal aorta can be life-saving to patients at risk for fatal aneurysm rupture, these operations remain challenging and are associated with substantial risk of early death and major complications. Additional improvements are needed to further reduce the risks associated with TAAA repair, particularly as increasing numbers of patients with advanced age and multiple or severe comorbidities present for treatment.
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Affiliation(s)
- Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; and Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, Texas, USA
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Patel VI, Lancaster RT, Conrad MF, Cambria RP. Open surgical repair of thoracoabdominal aneurysms - the Massachusetts General Hospital experience. Ann Cardiothorac Surg 2013; 1:320-4. [PMID: 23977514 DOI: 10.3978/j.issn.2225-319x.2012.09.02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2012] [Accepted: 09/06/2012] [Indexed: 11/14/2022]
Affiliation(s)
- Virendra I Patel
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Lancaster RT, Conrad MF, Patel VI, Cambria MR, Ergul EA, Cambria RP. Further experience with distal aortic perfusion and motor-evoked potential monitoring in the management of extent I-III thoracoabdominal aortic anuerysms. J Vasc Surg 2013; 58:283-90. [DOI: 10.1016/j.jvs.2013.01.042] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 01/15/2013] [Accepted: 01/16/2013] [Indexed: 10/26/2022]
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Scali ST, Waterman A, Feezor RJ, Martin TD, Hess PJ, Huber TS, Beck AW. Treatment of acute visceral aortic pathology with fenestrated/branched endovascular repair in high-surgical-risk patients. J Vasc Surg 2013; 58:56-65.e1. [PMID: 23706619 DOI: 10.1016/j.jvs.2012.12.043] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 12/05/2012] [Accepted: 12/09/2012] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The safety and feasibility of fenestrated/branched endovascular repair of acute visceral aortic disease in high-risk patients is unknown. The purpose of this report is to describe our experience with surgeon-modified endovascular aneurysm repair (sm-EVAR) for the urgent or emergent treatment of pathology involving the branched segment of the aorta in patients deemed to have prohibitively high medical and/or anatomic risk for open repair. METHODS A retrospective review was performed on all patients treated with sm-EVAR for acute indications. Planning was based on three-dimensional computed tomographic angiogram reconstructions and graft configurations included various combinations of branch, fenestration, or scallop modifications. RESULTS Sixteen patients (mean age [± standard deviation], 68 ± 10 years; 88% male) deemed high risk for open repair underwent urgent or emergent repair using sm-EVAR. Indications included degenerative suprarenal or thoracoabdominal aneurysm (six), presumed or known mycotic aneurysm (four), anastomotic pseudoaneurysm (three), false lumen rupture of type B dissection (two), and penetrating aortic ulceration (one). Nine (56%) had previous aortic surgery and all patients were either American Society of Anesthesiologists class IV (n = 9) or IV-E (n = 7). A total of 40 visceral vessels (celiac, 10; superior mesenteric artery, 10; right renal artery, 10; left renal artery, 10) were revascularized with a combination of fenestrations (33), directional graft branches (six), and graft scallops (one). Technical success was 94% (n = 15/16), with one open conversion. Median contrast use was 126 mL (range, 41-245) and fluoroscopy time was 70 minutes (range, 18-200). Endoleaks were identified intraoperatively in four patients (type II, n = 3; type IV, n = 1), but none have required remediation. Mean length of stay was 12 ± 15 days (median, 5.5; range, 3-59). Single complications occurred in five (31%) patients as follows: brachial sheath hematoma (one), stroke (one), ileus (one), respiratory failure (one), and renal failure (one). An additional patient experienced multiple complications including spinal cord ischemia (one) and multiorgan failure resulting in death (n = 1; in-hospital mortality, 6.3%). The majority of patients were discharged to home (63%; n = 10) or short-term rehabilitation units (25%; n = 4), while one patient required admission to a long-term acute care setting. There were no reinterventions at a median follow-up of 6.2 (range, 1-16.1) months. Postoperative computed tomographic angiogram was available for all patients and demonstrated 100% branch vessel patency, with one type III endoleak pending intervention. There were two late deaths at 1.4 and 13.4 months due to nonaortic-related pathology. CONCLUSIONS Urgent or emergent treatment of acute pathology involving the visceral aortic segment with fenestrated/branched endograft repair is feasible and safe in selected high-risk patients; however, the durability of these repairs is yet to be determined.
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Affiliation(s)
- Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL 32610, USA
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Smith PD, Bell MT, Puskas F, Meng X, Cleveland JC, Weyant MJ, Fullerton DA, Reece TB. Preservation of Motor Function After Spinal Cord Ischemia and Reperfusion Injury Through Microglial Inhibition. Ann Thorac Surg 2013; 95:1647-53. [DOI: 10.1016/j.athoracsur.2012.11.075] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 11/24/2012] [Accepted: 11/27/2012] [Indexed: 11/29/2022]
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Stone JH, Patel VI, Oliveira GR, Stone JR. Case records of the Massachusetts General Hospital. Case 38-2012. A 60-year-old man with abdominal pain and aortic aneurysms. N Engl J Med 2012; 367:2335-46. [PMID: 23234517 DOI: 10.1056/nejmcpc1209330] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- John H Stone
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, USA
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Smith PD, Puskas F, Meng X, Lee JH, Cleveland JC, Weyant MJ, Fullerton DA, Reece TB. The evolution of chemokine release supports a bimodal mechanism of spinal cord ischemia and reperfusion injury. Circulation 2012; 126:S110-7. [PMID: 22965970 DOI: 10.1161/circulationaha.111.080275] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Paraplegia remains a devastating complication of thoracic aortic surgery. The mechanism of the antecedent spinal cord ischemia and reperfusion injury (IR) remains poorly described. IR involves 2 injuries, an initial ischemic insult and subsequent inflammatory amplification of the injury. This mechanism is consistent with the clinical phenomenon of delayed onset paraplegia. This study sought to characterize the inflammatory response in the spinal cord after IR and hypothesized that this would support a bimodal mechanism of injury. METHODS AND RESULTS Male C57Bl/6 mice were subjected to 5 minutes of aortic arch and left subclavian occlusion with subsequent reperfusion to generate spinal cord ischemia. Functional outcomes were scored at 12-hour intervals. Spinal cords were harvested after 0, 6, 12, 18, 24, 36, and 48 hours of reperfusion. Cytokine levels were analyzed using a mouse magnetic bead-based multiplex immunoassay. Inflammatory chemokine concentrations (interleukin [IL]-1β, IL-6, keratinocyte-derived cytokine, macrophage inflammatory protein-1α, monocyte chemotactic protein-1, RANTES, and tumor necrosis factor-α) peaked at 6 hours and 36 to 48 hours after reperfusion. Functional scores reflected initial gain in function with subsequent decline, inversely proportional to cytokine levels. Immunofluorescent staining demonstrated microglia activation at 12 and 48 hours. CONCLUSIONS Spinal cord ischemia and reperfusion injury occurs in 2 phases, correlating to increases in inflammatory chemokines release and microglial activation. These observations chronologically parallel the too-common clinical syndrome of delayed-onset paraplegia. Understanding the molecular pathogenesis of this injury may allow future intervention to prevent this devastating complication.
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Affiliation(s)
- Phillip D Smith
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
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Efficacy and durability of endovascular thoracoabdominal aortic aneurysm repair using the caudally directed cuff technique. J Vasc Surg 2012; 56:53-63; discussion 63-4. [DOI: 10.1016/j.jvs.2012.01.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 01/03/2012] [Accepted: 01/04/2012] [Indexed: 11/22/2022]
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The Potential of Quantified Lower Cranial Nerve EMG for Monitoring of Anesthetic Depth. J Neurosurg Anesthesiol 2012; 24:139-45. [DOI: 10.1097/ana.0b013e3182401cef] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hsu CCT, Kwan GNC, van Driel ML, Rophael JA. Distal aortic perfusion during thoracoabdominal aneurysm repair for prevention of paraplegia. Cochrane Database Syst Rev 2012:CD008197. [PMID: 22419329 DOI: 10.1002/14651858.cd008197.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND During thoracoabdominal aortic aneurysm (TAAA) surgery, decreased spinal cord perfusion can result in neurological deficits such as paraplegia and paraparesis. Distal aortic perfusion, alone or in combination with other adjuncts, may counter the decrease in spinal cord perfusion and hence reduce the risk of spinal cord injury. OBJECTIVES To determine the effectiveness of distal aortic perfusion with or without other adjuncts against other adjuncts without use of distal perfusion during TAAA surgery in reducing the risk of developing paraplegia and paraparesis. SEARCH METHODS The Cochrane Peripheral Vascular Diseases Group Specialised Register (last searched 5 January 2012) and CENTRAL (Issue 4, 2011) were searched for publications describing randomised controlled trials of distal aortic perfusion during thoracoabdominal aortic aneurysm surgery. Reference lists of relevant studies were checked. SELECTION CRITERIA Randomised or quasi-randomised controlled clinical trials of distal aortic perfusion during TAAA repair. DATA COLLECTION AND ANALYSIS Studies identified for potential inclusion were independently assessed for inclusion by at least two authors, with excluded trials arbitrated by the third author. MAIN RESULTS There were no randomised controlled trials identified. AUTHORS' CONCLUSIONS Currently, there are no randomised controlled trials to support the role of distal aortic perfusion in TAAA surgery for prevention of neurological injury. However, randomised controlled trials are not always feasible based on ethical grounds. Observational studies suggest that distal aortic perfusion alone or in combination with other adjuncts, that is cerebrospinal fluid (CSF) drainage, reduces the rate of neurologic deficit across all types of TAAA; in particular making a striking difference in the rate of neurologic deficit following type II TAAA repair. In the absence of randomised controlled trials, we recommend a standardised approach to reporting through registry studies to strengthen the evidence base for distal aortic perfusion.
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Glycyrrhizin attenuates rat ischemic spinal cord injury by suppressing inflammatory cytokines and HMGB1. Acta Pharmacol Sin 2012; 33:11-8. [PMID: 22158106 DOI: 10.1038/aps.2011.151] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM To investigate the neuroprotective effect of glycyrrhizin (Gly) against the ischemic injury of rat spinal cord and the possible role of the nuclear protein high-mobility group box 1 (HMGB1) in the process. METHODS Male Sprague-Dawley rats were subjected to 45 min aortic occlusion to induce transient lumbar spinal cord ischemia. The motor functions of the animals were assessed according to the modified Tarlov scale. The animals were sacrificed 72 h after reperfusion and the lumbar spinal cord segment (L2-L4) was taken out for histopathological examination and Western blotting analysis. Serum inflammatory cytokine and HMGB1 levels were analyzed using ELISA. RESULTS Gly (6 mg/kg) administered intravenously 30 min before inducing the transient lumbar spinal cord ischemia significantly improved the hind-limb motor function scores, and reduced the number of apoptotic neurons, which was accompanied by reduced levels of tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β) and interleukin-6 (IL-6) in the plasma and injured spinal cord. Moreover, the serum HMGB1 level correlated well with the serum TNF-α, IL-1β and IL-6 levels during the time period of reperfusion. CONCLUSION The results suggest that Gly can attenuate the transient spinal cord ischemic injury in rats via reducing inflammatory cytokines and inhibiting the release of HMGB1.
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Emergency Abdominal Aortic Aneurysm Repair in a Patient with Failing Heart: Axillofemoral Bypass Using a Centrifugal Pump Combined with Levosimendan for Inotropic Support. Case Rep Vasc Med 2011; 2011:497940. [PMID: 22937463 PMCID: PMC3420771 DOI: 10.1155/2011/497940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Accepted: 10/10/2011] [Indexed: 11/17/2022] Open
Abstract
We describe the case of an 83-year-old patient requiring repair of a large symptomatic abdominal aortic aneurysm (AAA). The patient was known to have coronary artery disease (CAD) with symptoms and signs of significant myocardial dysfunction, left-heart failure, and severe aortic insufficiency. The procedure was performed with the help of both mechanical and pharmacological circulatory support. Distal perfusion was provided by an axillofemoral bypass with a centrifugal pump, with dobutamine and levosimendan administered as pharmacological inotropic support. The patient's hemodynamic status was monitored with continuous cardiac output monitoring and transesophageal echocardiography. No serious circulatory complications were recorded during the perioperative and postoperative periods. This paper suggests a potential novel approach to combined circulatory support in patients with heart failure, scheduled for open abdominal aortic aneurysm repair.
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